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Relation of socio-economic status to the

independent application of self-care in older
persons of South Africa

Tinda Rabie*, Hester C. Klopper, Martha J. Watson

INSINQ Focus Area, Faculty of Health Sciences, North-West University, Potchefstroom Campus, South Africa

article info abstract

Article history: Background: Many older persons in South Africa (SA) are affected by a poor socio-economic
Received 20 February 2015 status, leading to an increase in the use of the public healthcare sector. However, the public
Accepted 26 February 2015 healthcare sector is burdened by high volumes of patients and long waiting periods. As a
Available online 1 October 2015 result, professional nurses in primary healthcare (PHC) facilities are not able to spend
enough time on proper physical examinations and assessment of needs, including health
Keywords: education and support to older persons to help them apply independent self-care.
Older person Aim: To determine if the socio-economic status of older persons affects their ability to
Self-care apply self-care independently without support from professional nurses in the PHC facility.
Socio-economic status Design: Quantitative, descriptive research design.
Methods: Older persons (N ¼ 198; n ¼ 192 respondents) were asked to complete the
Appraisal of Self-care Agency (ASA-A) and Exercise of Self-care Agency (ESCA) question-
naires. Seven self-care deficits were identified through deductive logic after analysis of the
two questionnaires. These seven self-care deficits were compared to the socio economic
status of the same sample.
Results: Seven self-care deficits were identified after analysis of the ASA-A and ESCA
questionnaires. One self-care deficit was found to have a relationship with the socio-
economic status of the older persons.
Conclusions: Low literacy levels of older persons with a low socio-economic status affect
their ability to apply self-care independently without the support from a professional nurse
in the PHC facility. Data analysis of the ASA-A and ESCA revealed that these older persons
suffer from a “lack of knowledge and ability to acquire knowledge with regard to self-care”
which had a relationship with the socio-economic status of older persons with specific
reference to low literacy levels and poverty.
Implications for practice: More attention should be given to older persons with a low socio-
economic status as their ability to apply self-care independently without the support
from a professional nurse is limited. This would lead to less frequent visits to PHC facilities
by older persons for minor ailments, decrease healthcare costs, relieve overcrowding in
PHC facilities and prevent possible unintentional self-neglect.
© 2015 The Authors. Publishing services by Elsevier B.V. on behalf of Johannesburg Uni-
versity. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. North-West University, School of Nursing Science, South Africa. Tel.: þ27 18 299 1719.
E-mail addresses: tinda_rabie@yahoo.com (T. Rabie), klopperhc@gmail.com (H.C. Klopper), Mada.Watson@nwu.ac.za (M.J. Watson).
Peer review under responsibility of Johannesburg University.
http://dx.doi.org/10.1016/j.hsag.2015.02.007
1025-9848/© 2015 The Authors. Publishing services by Elsevier B.V. on behalf of Johannesburg University. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 hheeaal lt thhs sa ag ge es soonnddhheei d
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1. Introduction
Currently, ageing of the global population represents one of
the most distinctive changes in the demographic profile. In
parts of the population where there are scarce resources,
ageing has the potential to become a major issue, especially as
it has been predicted that the population of old people is going
to increase in the next two to three decades. Worldwide there
are 600 million people over the age of 60 years (World Health
Organization, 2013). The United Nation's estimated projec-
tion of older persons in 2000 was 21.3 million, with the figure
expected to rise to 80.3 million in 2025. Sub-Saharan Africa has
a lower number of older persons compared to other devel-
oping regions (Kimuna, 2005, p. 13). According to Nabalamba
and Chikoko (2011, p. 2), the older population in Africa ac-
counts for 3.6% of the entire population and this percentage is
expected to rise to 4.5% in 2030 and to 10% in 2050. In South
Africa in 2001 there were 3.3 million persons over 60 years of
age (Turok, 2006, p. 1), which represented 7.5% of the total
population; this number has since increased to 7.7% (Statistics
SA, 2011). In the North West (NW) province the 2011 census
revealed that the percentage of older persons (60 þ years of
age) increased to 7.7% (Statistics SA, 2011) from 7.34% in 2001
(Joubert & Bradshaw, 2004, p. 152). The reality of the increasing
older population is putting increased pressure on the public
healthcare sector serving 83% of the total South African pop-
ulation (Council of Medical Schemes, 2011). This means that
professional nurses are not able to spend enough time on
physical examinations and health education focusing on in-
dependent application of self-care in the PHC facilities.
Additionally, older persons have different socio-economic
needs that should be considered; for example accessibility of
healthcare, needs regarding nutrition, shelter, clothing,
transportation, community amenities and various types of
abuses (May, 2003). Previous health experiences, the nature of
medical complaints, past experiences at healthcare services,
requests for information and advisory visits to healthcare fa-
cilities are all issues that are faced by older persons (Laditka,
2004, p. 233;Voz ehova , Zikmundova , Zava zalova , Zaremba, &
Vlasa k, 2003, p. 48) together with the reality of a low socio-
economic status (Nabalamba & Chikoko, 2011, p. 12). The
studied population is also affected by a low-socio-economic
status, low literacy levels and poverty. Due to the latter, they
have no other choice than to visit PHC facilities which is the
first point of access to healthcare for patients in the public
healthcare sector.
PHC was introduced in South Africa in 1994 to reform the
health services. The focus of PHC is to make essential services
freely available, cost-effective, affordable and equal to all
members of the population, and includes the care and treat-
ment of chronic and other diseases in older persons (Hattingh,
Dreyer, & Roos, 2010, p. 65; Phaswana-Mfuya et al., 2008, pp.
611e612). According to Hattingh, Dreyer, and Roos (2012, p.
70), PHC stresses self-reliance and self-determination and
therefore aims to redistribute power and build self-confidence
in people. This also applies to older persons and should be
able to assist them to increase their independence in caring
for self. Self-care among older persons has the potential to
reduce medical care needs as well as healthcare costs (Joubert
e16 61 1
& Bradshaw, 2004, p. 157; Lloyd-Sherlock, 2004, pp. 292e294;
SA, 2004, p. 3).
However, according to The DG Murray Trust (2012:4), the
healthcare provided to older persons in the public sector is not
satisfactory. This could be due to a lack of expertise in the care of
older people, leading to a systematic failure of the system. Other
factors in the public healthcare sector which possibly also affect
the older person to independently apply self-care include inef-
fective appointment arrangements, lack of medication, poor
handling of physical examinations (Turok, 2009, p. 1), over-
crowding, long waiting periods, staff shortages, inadequate
provision of health education to specifically older persons, poor
quality of care and disrespect (Kruger, Greeff, Watson, & Fourie,
2009, p. 42). This uncaring attitude is not intentionally inflicted
on older persons in the PHC facilities, but is rather as a result of
factors such as time constraints, staff shortages, high work-
loads and overcrowded public PHC facilities which lead to
frustration among the staff (Bradshaw & Steyn, 2001, p. 9; Turok,
2006, p. 5). More attention should thus be given to the man-
agement of older persons' health problems and their indepen-
dent self-care abilities in PHC facilities.
If older people do not have sufficient knowledge about their
healthcare problems, including their chronic diseases, they
will not know how to independently treat or take care of
themselves, and the less they know, the less they will discuss
any issues they have with the healthcare provider, thereby
decreasing their self-care ability (Guinn, 2004, p. 270; Bastiaens,
Van Royen, Rotar Pavlic, Raposo, & Baker, 2007, p. 38).
Gibbons (2006, p. 324) mentions that self-care means pur-
poseful management of the self and could be considered
intentional. Other authors such as Kendall and Rogers (2007,
p. 130) and Lauder (2001, p. 96) describe self-care as activities a
person engages in to promote health, prevent disease, assess
symptoms and reinstate optimal healthy functioning. Self-
care also includes those actions a person engages in to
ensure optimal health for a long period of time or to preserve
health and ensure healthy functioning by taking part in self-
development activities in order to prevent self-neglect
(Tomey, & Alligood, 2006, p. 269).
Self-care encompasses the following concepts: self-care
agency, self-care agent and self-care deficit (Orem, 2001, pp.
53; 268 & 282). Self-care agency refers to the ability (capability
and power) a person has to engage in self-care operations
(Callaghan, 2006, p. 45; Evers, Isenberg, Philipsen, Senten, &
Brouns, 1993, p. 332; Lauder, 2001, p. 96; Orem, 2001, p. 53;
Tomey & Alligood, 2006, p. 271). Self-care agent refers to the
individual who engages in self-care (Orem, 2001, p. 268;
Tomey & Alligood, 2006, p. 271), and self-care deficit refers to
the limitations in the self-care ability and power of the self-
care agent to meet therapeutic self-care demands (Orem,
2001, p. 282). Lastly, self-neglect means that a person is not
able to provide goods or services to self to meet basic needs
(Deyer, Goodwin, Pickens-Pace, Burnett, & Kelly, 2007, p.
1671).
The initial healthcare profile obtained during the Prospec-
tive Urban and Rural Epidemiological study (PURE) (Kruger,
2005, p. 4) revealed that the studied older population had a
low socio-economic status and was affected by low literacy
levels and poverty (Watson, 2008, pp. 72e74) (see Table 1). The
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literature mentions the following factors that affect the older
populations' ability to independently apply self-care, which
may lead to self-neglect.
Many older persons affected by poor health and chronic
diseases stay in their own residences and not in old-age
homes. This is because they cannot afford to stay in old-
age homes, where professional nurses can support them
in the independent application of self-care to manage their
diseases.
Older persons are not a priority in South African healthcare
(Ntusi & Ferreira, 2004, p. 3).
Most older persons do not have any general knowledge
about their health conditions and how to handle these
conditions (Deyer et al., 2007, p. 1672).
The majority of older persons (55%) in the studied popu-
lation mentioned above have no or only primary education.
This excludes them from searching, finding and reading
information about self-care (see Table 1).
Most of the older persons cannot afford a private medical
fund and form part of the 83% of the general population
who must visit PHC facilities in the public healthcare sector
(Council of Medical Schemes, 2011), which is burdened by
overcrowding, long waiting times, staff shortages and poor
quality of care (Kruger et al., 2009, pp. 42 & 43).
Poverty contributes to a lack of healthcare seeking behav-
iour (Kruger et al., 2009, p. 42), especially in view of the
travelling costs and physical challenges involved in
attending a PHC facility.
2. Method
The research method involved participants, sampling, data
collection, data analysis, reliability and validity.
2.1. Participants and sampling
This study made use of a quantitative, descriptive research
design and was embedded in the larger PURE-SA study
(Kruger, 2005). The participants were made up of a proportion
of the older persons who participated in the PURE-SA study
and lived in their private residences in a semi-urban district of
Potchefstroom, in the North West in South Africa. A total
number of 198 questionnaires were disseminated to the par-
ticipants for completion, and 192 were returned resulting in a
98% response rate. The healthcare profile data was obtained
as part of the initial data collection of the PURE-SA study on
the same older population. The healthcare profile included the
bio-physical, psychological well-being, and socio-economic
factors, lifestyle behaviour and support system (Table 1)
(Watson, 2008, pp. 72e74). For the purpose of this study the
researchers only used the data focusing on the socio-
economic factors of the studied population.
2.2. Data collection
Data was collected in two phases.
e16 61 1 157
2.2.1. Phase 1
The healthcare profile of the older population was obtained
during the initial PURE data collection process. As mentioned
previously, the healthcare profile included information on the
biophysical, psychological well-being and socio-economic fac-
tors, lifestyle behaviour and support system. For the purpose of
this article the researchers only focused on the socio-economic
factors which included the educational profile, main source of
income, number of persons living in the houses of the older
persons being studied, household conditions and social support.
2.2.2. Phase 2
The researchers employed two structured questionnaires, the
ASA-A developed in 1988 by Evers et al. (1993) and the ESCA
developed by Kearny and Fleischer (1979), based on Dorothea
Orem's self-care deficit theory of nursing which focuses on
measuring the self-care ability of a person. Before the ques-
tionnaires were used, permission was asked and obtained
from the developers of both the ASA-A and ESCA. The re-
searchers, with the assistance of Setswana-speaking field-
workers, firstly conducted a pilot study to identify any
problems that could be encountered during data collection.
After the pilot study the researchers made some minor
adapatations, which included translation of the question-
naires into Setswana and changing the original 5-point Likert
scale to a 3-point Likert scale to fit the older Setswana-
speaking population. This was done because the studied
population was Setswana speaking and 29% had no education
and 55% had only a primary education (see Table 1). The
fieldworkers mentioned after the pilot study that they them-
selves and the participants would understand the question-
naires better in their mother tongue which was Setswana.
Before the fieldworkers started with the data collection,
each of the participants was provided with a letter that pro-
vided background information on the study and explained the
purpose of the study. The letter also provided the ethical
approval number and voluntary consent from. The field-
workers then verbally explained the abovementioned infor-
mation and therafter obtained consent before starting with
the data collection. The fieldworkers, mainly Setswana
speaking, completed the questionnaires on behalf of the older
persons who where not literate by verbally asking the ques-
tions on both questionnaires and recording the answer on the
questionnaire as provided by the older person.
2.3. Data analysis
Data analysis was conducted in two phases.
2.3.1. Phase 1
The healthcare profile was analysed during inital data
collection by Watson (2008, pp. 72e74). Descriptive statistics
were obtained after analysis of the healthcare profile (which
included the socio-economic status) of the older persons by
using SPSS 15.1 for Windows (1989e2008) (see Table 1).
2.3.2. Phase 2
The self-care ability (capability and power) of the older person
was examined by using descriptive statistics. Descriptive
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statistics assessed the variable distribution which provided

the opportunity to arrange the data in such a manner that it
could be understood, and to give meaning to the phenomenon
of self-care from various angles (Burns & Grove, 2005, p. 375;
Maree et al., 2012, p. 19).
2.4. Reliability and validity
The fieldworkers who assisted in data collection of the ASA-
A and ESCA were part of the initial PURE-SA study and
therefore knew the studied population. The fieldworkers also
received training prior to the data collection on completion
of the questionnaires and on each and every question asked.
The questionnaires had a high Cronbach's alpha coefficient
after analysis - Cronbach's alpha coefficient of the ASA-A
was .79 and for the ESCA it was .89, indicating a high
reliability.
3. Ethical considerations
The study was approved by the NWU ethics committee and
formed part of the PURE-SA study that focuses on older per-
sons (ethical approval Number 04M10). The participants of
the study were mainly Setswana speaking and had low liter-
acy levels. The researchers thus used Setswana-literate
fieldworkers for data collection so that they could explain
the background information and the purpose of the study to
the participants in their mother tongue, i.e. Setswana. The
participants were also informed that participation was
voluntary and that they could withdraw at any time with
no penalty against them. They were also assured of confi-
dentiality. Before the data collection commenced, all partici-
pants gave voluntary consent by signing (or marking) a
consent form. Throughout the study care was taken to
maintain confidentially and anonymity of all the information.
4. Results
The results of this study were obtained in two phases, which
included both the results of the socio-economic status which
formed part of the initial healthcare profile obtained by
Watson (2008, pp. 72e72) of the studied older population and
the self-care deficits deducted from the ASA-A and ESCA
questionnaires.
4.1. Phase 1
4.1.1. Socio economic status
South Africa is burdened with severe inequality and poverty
(Kinkel, Marcus, Memon, Bam, & Hugo, 2013, p. 2). The socio-
economic profile of the studied older persons supports this
statement as it indicated that the older persons had a poor
educational profile, with 29% having no education, 55% having
primary education and only 10% of the population having a
secondary education (see Table 1). According to Statistics SA
(2012, p. 116), 38% of the total black older population of SA
has no primary education, which means that older persons
living in the North West showed a slightly higher literacy level
than the average older person in South Africa (see Table 1).
Older persons in South Africa are reliant on a grant (older
persons grant) each month (Statistics SA, 2012, p. 116). This
was also true for the studied population. It was found that 72%
received an older persons grant, 7% were employed, 5%
received money from their family and 8% had no income (see
Table 1). The percentage of 72% of older persons receiving an
older persons grant is in line with 69% (in 2011) of the South
African population receiving an older persons grant each
month (Statistics SA, 2012, p. 116). In the houses of the older
persons, 95% had orphans or other persons living with them
(see Table 1). This percentage correlates very well with the
greater South African population as according to Statistics SA
(2012, p. 115), the child dependence ratio in households where

Table 1 e Socio-economic profile of the studied population (N ¼ 198).

Educational profile None: n ¼ 57 29%
Primary: n ¼ 108 55%
Secondary: n ¼ 20 10%
Missing: n ¼ 13 6%
Main source of income Pension: n ¼ 142 72%
Employed by themselves/other n14 7%
person/other organisation:
Family: n ¼ 9 5%
No income: n ¼ 18 8%
Missing: n ¼ 15 8%
Number of people living in 6 n ¼ 44 22%
houses of older persons 6 n ¼ 145 73% (5% missing)
Household conditions Electricity: n ¼ 174 88% (8% ¼ No; 4% missing)
Roof: n ¼ 183 92% (3% ¼ No; 5% missing)
Water supply: (Piped) n ¼ 142 72% (23% community well/bore hole;
1% fetch from river/dam; 4% missing)
Social support Family: n ¼ 44 22%
Children: n ¼ 7 3.5%
Community: n ¼ 9 4.5%
No support: n ¼ 0 0%
Other: n ¼ 138 70%
159 hheeaal lt thhs sa ag ge es so on nddhhe ei d
older persons stayed was an average of 1.24. In 22% of the
households there were more than six persons living in the
household and in 73% there were less.
Overall, the conditions of the respective households were
relatively acceptable as the following percentages were re-
ported: 88% had electricity and 72% had piped water supply
(see Table 1). These statistics reflects the finding of Statistics
SA (2012, p. 117) which found that since 2002 older persons
were more likely to have access to resources such as piped
water, flush toilets and electricity. From Table 1 it can be seen
that 22% of the older persons' family supported them, 3.5%
children supported them, 4.5% had support from the com-
munity, and 70% had other forms of support. The latter is also
true of the general SA population where, according to
Statistics SA (2012, p. 115), older persons not only provide, but
also depend on social support networks.
4.2. Phase 2
4.2.1. Self-care deficits
Analysis of both the completed ASA-A and ESCA question-
naires enabled the researchers to deduct seven self-care
deficits based on Dorothea Orem's self-care theory of
nursing (see Table 2). The following self-care deficits were
found in older persons: deficit in time management skills; an
energy deficit; sleep deprivation; a lack of knowledge and
ability to acquire knowledge with regard to health and self-
care; a lack of rest, exercise and self-care programme; a
deficit caused by physical deterioration; and lastly, they
experience a lack in the performance of activities to prevent/
decrease self-care deficits.
Table 2 e Self-care deficits identified in the ASA-A and ESCA (N ¼ 198).
Self-care deficits
The older person has a deficit in time
management skills, affecting self-care.
The older person has an energy deficit, affecting
self-care.
The older person has a sleep deprivation deficit.
The older person has a lack of knowledge and
ability to acquire knowledge with regard to
health and self-care.
The older person has lack of a rest, exercise and
self-care programme.
The older person has a self-care deficit caused by
physical deterioration.
The older person experiences a lack in the
performance of activities to prevent/decrease
self-care deficits.
5. Discussion
From the identified self-care deficits (see Table 2) only one had
a relationship with the socio-economic status of the studied
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population, namely “lack of knowledge and ability to acquire
knowledge with regard to health and self-care”. This could be
due to the low socio-economic status which more specifically
includes low literacy levels and poverty. These factors and
factors such as time constraints, staff shortages, high work-
loads and overcrowding in PHC facilities affect the older per-
sons' ability to independently apply self-care. .
However, PHC focuses on giving back the power to the
patient, including the older person with low socio-economic
status, so that they can become more independent and self-
reliant to apply self-care. It is therefore vital that PHC facil-
ities provide additional support on the independent applica-
tion of self-care to ensure optimal health for the older
persons, in particular those with a lower socio-economic
status who are more likely to be lacking in knowledge and
who thus need to acquire knowledge with regard to health
and self-care.
6. Recommendations for further research
The following research recommendations are suggested to
assist older persons affected by low socio-economic status in
the independent application of self-care:
The perceptions of professional nurses should be explored
with regard to the implementation of measures to assist
older persons in the independent application of self-care.
The perceptions of clinic staff and older persons should be
examined with regard to the importance of the application
on self-care.
Items of the ASA-A and ESCA indicating the self-care deficits after
analysis of descriptive statistics
ASA-A: Items 20 and 23
ESCA: Items 20 and 25
ASA-A: Items 6,9 and 13
ESCA: Items 3, 15 and 37
ASA-A: Items 6 and 13
ESCA: Item 3
ASA-A: Items 2, 5, 14 and 15 (Lack of knowledge)
ASA-A: Items 14, 15, 16, 21 and 22 (Lack of ability to acquire knowledge)
ESCA: Items13, 24, 28 and 35 (Lack of knowledge)
ESCA: Items 4, 8, 17, 19, 22 and 40 (Lack of ability to acquire knowledge)
ASA-A: Items 11, 13 and 19
ESCA: Items 25 and 29
ASA-A: Items 3 and 24
ESCA: 0 items
(ASA-A: Items 1, 7, 9, 17, 18, 19 and 22
ESCA: Items 5, 6, 8, 10, 13, 15, 16, 17, 19, 22, 25, 28, 30, 33, 38, 39, 40 and 42)
Research needs to be conducted on the feasibility of the
regular implementation of well-planned self-care health
education sessions for older persons in order to assist them
in the independent application of self-care.
The level of commitment of older persons to apply self-
care needs to be explored in more depth.
160 hheeaal lt thhs sa ag ge es so on nddhhe ei d
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Research on the self-care ability of older persons in South
Africa in different cultures and in different socio-economic
situations should be done.
7. Limitations of this study
The PURE-SA study did not include all the older persons in the
peri-urban district of Potchefstroom, and therefore the results
could only be used as a general guide for other older pop-
ulations. The participants of this study were predominantly of
the Setswana ethnic group and thus the results may not be
representative of other ethnic groups and can only be used as
a general guideline.
8. Implications for practice
PHC facilities supporting older persons to independently
apply self-care could decrease unnecessary healthcare costs
caused by older persons who lack the self-care knowledge
required to manage minor health problems. Such facilities
would assist in improving the quality of life of older persons,
healthcare costs would drop and overcrowding at PHC facil-
ities would be alleviated because minor ailments would have
been independently handled by the older person. The older
person would also be saved from unnecessarily attending a
PHC facility where they are confronted with overcrowding and
long waiting periods to manage a minor health problem they
could have managed by themselves.
9. Conclusion
Older persons in the studied population had a low socio-
economic status and were especially affected by low literacy
levels and poverty. Data analysis of the ASA-A and ESCA to
determine the ability of older persons to apply self-care
revealed that there was a lack of knowledge and an inability
to acquire knowledge by themselves with regard to self-care.
The older population thus needs support from professional
nurses in PHC facilities to help them apply self-care inde-
pendently. By giving this support to older persons, the PHC
service model in the public healthcare sector can play a vital
role as it aims to promote self-reliance and independence by
giving people back their power and self-confidence. This
approach would also assist in reducing medical needs,
healthcare costs, overcrowding and long waiting periods.
Authors' contributions
Dr T. Rabie was a postgraduate student and Prof. H.C. Klopper
and Dr. M.J. Watson were the promoters who assisted Dr. T.
Rabie in the development of this article.
Acknowledgements
The authors would like to thank all supporting staff and the
participants of the PURE-South Africa study and in particular
the following:
e16 61 1 160
1. The PURE-SA research team, and in particular Prof
Annamarie Kruger, the principal investigator and coordinator
of the South African leg of PURE; Dr Mada Watson who was
responsible for the gerontology data used in this study, field
workers and office staff in the Africa Unit for Trans-
disciplinary Health Research (AUTHeR), Faculty of Health
Sciences, North-West University, Potchefstroom, South
Africa.
2. Funders of the PURE-SA study: SANPAD (South Afri-
caeNetherlands Research Programme on Alternatives in
Development), South African National Research Foundation
(NRF GUN numbers 2069139 and FA2006040700010), North-
West University, the Population Health Research Institute in
Ontario Canada and the Medical Research Council of SA.
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